Cochrane Review: Continuous heparin infusion to prevent thrombosis and catheter occlusion in neonates with peripherally placed percutaneous central venous catheters

Abstract

AbstractBackgroundComplications associated with peripherally placed percutaneous central venous catheters (PCVC) in neonates include mechanical complications (catheter thrombosis, occlusion or dislodgement) and infection. Strategies to prevent catheter thrombosis and occlusion include the use of heparin. However, heparin is known to be associated with complications such as bleeding and thrombocytopenia.ObjectivesPrimary objective: To assess the effectiveness of heparin for prevention of catheter related thrombosis.Secondary objectives: To assess the effectiveness of heparin on catheter occlusion, duration of catheter patency, catheter related sepsis and complications associated with the use of heparin.Search strategyA literature search of MEDLINE, EMBASE, CINAHL from their inception to December 2007, The Cochrane Library (Issue 4, 2007) and abstracts from the annual meetings of the Pediatric Academic Societies was performed without language restrictions.Selection criteriaRandomized or quasi‐randomized clinical trials of neonates where heparin infusion was compared to placebo or no treatment for prevention of any of the complications related to peripherally placed PCVC were included.Data collection and analysisThe methodological quality of included trials was assessed using criteria for masking of randomization, masking of intervention, completeness of follow‐up and masking of outcome measurement. Data on relevant outcomes were extracted and the effect size was estimated by calculating relative risk (RR), risk difference (RD) and associated 95% confidence intervals (CI).Main resultsThree randomized trials were identified. Two trials of adequate methodology met the eligibility criteria. These studies included 267 neonates. There was reduced risk of catheter occlusion (typical RR 0.28, 95% CI 0.15, 0.53, NNT 5, 95% CI 3, 8). There was no statistically significant difference in the duration of catheter patency when analyzed as continuous data; however, in one study survival analyses identified benefit with heparin (adjusted hazard ratio 0.55, 95% CI 0.36, 83); (Shah 2007). This could be due to higher incidence of elective removal of catheters in neonates at the completion of therapy in the heparin group (63% vs. 42%; p = 0.002) (Shah 2007). There was no statistically significant differences in the risk of thrombosis (typical RR 0.93, 95% CI 0.58, 1.51), catheter related sepsis (typical RR 1.96, 95% CI 0.50, 7.60), or extension of intraventricular hemorrhage (typical RR 0.87, 95% CI 0.25, 3.03) between the two groups.Authors' conclusionsImplications for practice: Prophylactic use of heparin for peripherally placed PCVC allows a greater number of infants to complete their intended use (complete therapy) by reducing occlusion. Evidence from this systematic review support the prophylactic use of heparin for PCVC in neonates at a dose of 0.5 IU/kg/hr.Implications for research: None of these studies was powered to evaluate a lower incidence rate of adverse events. If this therapy is adopted in routine practice, monitoring of side effects is indicated.Plain Language SummaryContinuous heparin infusion to prevent thrombosis and catheter occlusion in neonates with peripherally placed percutaneous central venous cathetersThere is now evidence to show the effect of heparin for preventing complications when used with central catheters to give access to the tiny veins of premature and critically ill babiesCritically ill or premature babies (born before 37 weeks of pregnancy) often need medication and feeding through their veins. These veins are small and fragile so repeated injections can be hard and painful for the baby. A central catheter is a small tube that can be inserted into the vein, allowing medications and other liquids to be given to the baby for a prolonged period. It can get dislodged, blocked or infected. The drug heparin allows to complete intended therapy in more patients without increasing complications of bleeding or allergic reactions. The review found that there was now evidence to show benefit of heparin. If it is used routinely, careful monitoring of side effects is warranted.